GW1-2022-02976_Well Construction - GW1_20220228

L L U U NO I tt U U I I U N ti t U U M U U YV-I Por Internal Use Unly: I
I Contractor
Information:
(f,U,U rht n 14.WATER ZONES
F
Well ContractorjN FROM TO DESCRIPTION�am ft ft /�
ft.
NC We ff-
Contractor Certification Number 15.OUTER CASING for multi-casAZells O E LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
( ft. I ft_ in. r
Company Name 16.INNER CASING OR TUBING eothermalclosed-loo V
2.Well Construction Permit#: W r��' 0�1� / FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, liarJance,etc.) ft. ft. in.
3. Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural ©MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) M<Qemial Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO ERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 0'� ft. W'1 -rcip- .
Monitoring Recovery 46ft. ft.
Injection Well: u� T�
ft. ft.
Aquifer Recharge []Groundwater Remediation x
Aquifer Storage and Recovery [] 19.SAND/GRAVEL PACK(if alicableSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
so
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness, ii/rock type,grain size,etc.Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: / 2z Z/ Well ID# ft. ft.
Q
5a.Well Location: Aft.
ft.
4021�P t//r_`44 r J�(� P. ft. ft.
FaciQlityy/OwnePName C/ Facility M#(if applicable)
U Q �1 L� / D ft. ft. L -
Physical Address,City,and Zip ft. ft. Pr ;s4*0*
�.Cinr►�_ OF�lga�7d37 21.REMARKS
County Parcel Identification No_(PIN)
5b. Latitude and longitude in deg rees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. Certification:
N W
6.Is(are)the well(s) Permanent or []Temporary Signature o Cedf ed Wen contractor Date
By signing this form, 1 hereby certify that the we11(5)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under,f21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list atl depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources, Information Processing Unit,
If water level is above casing,use,. 1617 Mail Service Center, Raleigh,NC 27699-1617
i
11.Borehole diameter: p (jn.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction t0 the following:
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh,NC 27699-1636
13a.Yield(gpm) . Method of test: 24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: dL completion of well construction to the county health department of the county
where constructed.
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